GriefGrief?is a multi-faceted response to loss, particularly to the loss of someone or something to which a bond was formed. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions. While the terms are often used interchangeably, bereavement refers to the state of loss, and grief is the reaction to loss.DefinitionGrief is a natural response to loss. It is the emotional suffering one feels when something or someone the individual loves is taken away.[1]?Grief is also a reaction to any loss. The grief associated with death is familiar to most people, but individuals grieve in connection with a variety of losses throughout their lives, such as unemployment, ill health or the end of a relationship.[2]?Loss can be categorised as either physical or abstract,[3]?the physical loss being related to something that the individual can touch or measure, such as losing a spouse through death, while other types of loss are abstract, and relate to aspects of a person?s social interactions.[4Grieving processEvery step of the process is natural and healthy, it is only when a person gets stuck in one step for a long period of time then the grieving can become unhealthy, destructive and even dangerous. When going through the grieving process it is not the same for everyone, but everyone does have a common goal, acceptance of the loss and to always keep moving forward.[5]?This process is different for every person but can be understood in four different steps.Shock and DenialShock is the initial reaction to loss. Shock is the person?s emotional protection from being too suddenly overwhelmed by the loss. The person may not yet be willing or able to believe what their mind knows to be true. This stage normally lasts two or three months.Intense ConcernIntense concern is often shown by not being able to think of anything else. Even during daily tasks, thoughts of the loss keep coming to mind. Conversations with one at this stage always turn to the loss as well. This period may last from six months to a year.Despair and DepressionDespair and depression is a long period of grief, the most painful and protracted stage for the griever (during which the person gradually comes to terms with the reality of the loss). The process typically involves a wide range of feelings, thoughts, and behaviors. Many behaviors may be irrational. Depression can include feelings of anger, guilt, sadness and anxiety.RecoveryThe goal of grieving is not the elimination of all the pain or the memories of the loss. In this stage, one shows a new interest in daily activities and begins to function normally day to day. The goal is to reorganize one?s life, so the loss is an important part of life rather than its center.[6][7][edit]ReactionsCrying?is a normal and natural part of grieving. It has also been found, however, that crying and talking about the loss is not the only healthy response and, if forced or excessive, can be harmful.[8][9]?Responses or actions in the affected person, called "coping ugly" by researcher?George Bonanno, may seem counterintuitive or even look dysfunctional, such as celebratory responses, laughter, self-serving bias in interpreting events.[10]?Lack of crying is also a natural, healthy reaction, potentially protective of the individual, and may also be seen as a sign of resilience.[8][9][11]?Science has found that some healthy people who are grieving do not spontaneously talk about the loss. Pressing people to cry or retell the experience of a loss can be harmful.[9]?Genuine?laughter?is healthy.[8][11][edit]Five identities of grieversBerger identifies five ways of grieving, as exemplified by:The nomadsNomads have not yet resolved their grief and do not seem to understand the loss that has affected their?lives.The memorialistsThis identity is committed to preserving the memory of the loved one that they have lost.The normalizersThis identity is committed to re-creating a sense of family and community.The activistsThis identity focuses on helping other people who are dealing with the same disease or with the same issues that caused their loved one's death.The seekersThis identity will adopt religious, philosophical, or spiritual beliefs to create meaning in their lives.[12][edit]Bereavement scienceGrief can be caused by the loss of one's home and possessions, as occurs with refugees.[edit]Bonanno's Four Trajectories of GriefMain article:?George BonannoGeorge Bonanno, a?professor?of?clinical psychology?at?Columbia University, conducted more than two decades of scientific studies on grief and trauma, which have been published in several papers in the most respected peer-reviewed journals in the field of psychology, such as?Psychological Science?and The?Journal of Abnormal Psychology. Subjects of his studies number in the several thousand and include people who have suffered losses in the U.S. and cross-cultural studies in various countries around the world, such as?Israel,?Bosnia-Herzegovina, and China. His subjects suffered losses through war,?terrorism, deaths of children, premature deaths of spouses,?sexual abuse, childhood diagnoses of AIDS, and other potentially devastating loss events or potential trauma events.In Bonanno's book, "The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss" (ISBN 978-0-465-01360-9), he summarizes his research. His findings include that a natural resilience is the main component of grief and trauma reactions.[8]?The first researcher to use pre-loss data, he outlined four trajectories of grief.[8]?Bonanno's work has also demonstrated that absence of grief or trauma symptoms is a healthy outcome, rather than something to be feared as has been the thought and practice until his research.[10]?Because grief responses can take many forms, including laughter, celebration, and bawdiness, in addition to sadness,[11][13]?Bonanno coined the phrase "coping ugly" to describe the idea that some forms of?coping?may seem counter intuitive.[10]?Bonanno has found that resilience is natural to humans, suggesting that it cannot be "taught" through specialized programs[10]?and that there is virtually no existing research with which to design resilience training, nor is there existing research to support major investment in such things as military resilience training programs.[10]The four trajectories are as follows:Resilience: "The ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event, such as the death of a close relation or a violent or life-threatening situation, to maintain relatively stable, healthy levels of psychological and physical functioning" as well as "the capacity for generative experiences and positive emotions."Recovery: When "normal functioning temporarily gives way to threshold or sub-threshold?psychopathology?(e.g., symptoms of depression or?Posttraumatic stress disorder, or PTSD), usually for a period of at least several months, and then gradually returns to pre-event levels."Chronic dysfunction: Prolonged suffering and inability to function, usually lasting several years or longer.Delayed grief or trauma: When adjustment seems normal but then distress and symptoms increase months later. Researchers have not found evidence of?delayed grief, but delayed trauma appears to be a genuine phenomenon.[edit]Five stages theoryMain article:?K?bler-Ross modelThe?K?bler-Ross model, commonly known as the five stages of grief, is a theory first introduced by?Elisabeth K?bler-Ross?in her 1969 book,?On Death and Dying.[14]?The popular but largely untested theory describes in five distinct stages how people deal with grief and?tragedy. Such events might include being diagnosed with a terminal illness or enduring a catastrophic loss. The five stages are denial, anger, bargaining, depression, and acceptance.The theory holds that the stages are a part of the framework that helps people learn to live without what they lost. Lay people and practitioners consider the stages as tools to help frame and identify what a person who's suffered a loss may be feeling. The theory holds that the stages are not stops on a linear time line of grief. The theory also states that not everyone goes through all of the stages, nor in a prescribed order. In addition to the five-stages theory, K?bler-Ross has been credited with bringing mainstream awareness to the sensitivity required for better treatment of people who are dealing with a fatal disease.[15]The stages model, which came about in the 1960s, is a theory based on observation of people who are dying, not people who experienced the death of a loved one. This model found empirical support in a study by Maciejewski et al.[16]?The research ofGeorge Bonanno, however, is acknowledged as inadvertently debunking the five stages of grief because his large body of peer-reviewed studies show that the vast majority of people who have experienced a loss do not grieve, but are resilient. The logic is that if there is no grief, there are no stages to pass through.[17][edit]Physiological and neurological processes"Piet?" by?El Greco, 1571-1576. Philadelphia Museum of ArtStudies of?fMRI?scans of women from whom grief was elicited about the death of a mother or a sister in the past 5 years resulted in the conclusion that grief produced a local inflammation response as measured by salivary concentrations of?pro-inflammatory cytokines. These responses were correlated with activation in the?anterior cingulate cortex?and?orbitofrontal cortex. This activation also correlated with the free recall of grief-related word stimuli. This suggests that grief can cause stress, and that this reaction is linked to the emotional processing parts of the?frontal lobe.[18]?Activation of the anterior cingulate cortex and?vagus nerve?is similarly implicated in the experience of?heartbreakwhether due to social rejection or bereavement.Among those persons who have been bereaved within the previous three months of a given report, those who report many intrusive thoughts about the deceased show ventralamygdala?and rostral?anterior cingulate cortex?hyperactivity to reminders of their loss. In the case of the amygdala, this links to their sadness intensity. In those individuals who avoid such thoughts, there is a related opposite type of pattern in which there is a decrease in the activation of the dorsal amgydala and the?dorsolateral prefrontal cortex.In those not so emotionally affected by reminders of their loss, studies of?fMRI?scans have been used to conclude that there is a high functional connectivity between the dorsolateral prefrontal cortex and amygdala activity, suggesting that the former regulates activity in the latter. In those people who had greater intensity of sadness, there was a low functional connection between the rostal anterior cingulate cortex and amygdala activity, suggesting a lack of regulation of the former part of the brain upon the latter.[19][edit]RisksBereavement, while a normal part of life, carries a degree of risk when severe. Severe reactions affect approximately 10% to 15% of people.[8]?Severe reactions mainly occur in people with depression present before the loss event.[8]?Severe grief reactions may carry over into family relations. Some researchers have found an increased risk of marital breakup following the death of a child, for example. Others have found no increase.Many studies have looked at the bereaved in terms of increased risks for stress-related illnesses.?Colin Murray Parkes?in the 1960s and 1970s in England noted increased doctor visits, with symptoms such as abdominal pain, breathing difficulties, and so forth in the first six months following a death. Others have noted increased mortality rates (Ward, A.W. 1976) and Bunch et al. found a five times greater risk of?suicide?in teens following the death of a parent.[20][edit]Complicated griefProlonged Grief Disorder (PGD), formerly known as complicated grief, is a pathological reaction to loss representing a cluster of empirically-derived symptoms that have been associated with long-term physical and psycho-social dysfunction. Individuals with PGD experience severe grief symptoms for at least six months and are stuck in a maladaptive state.[21]?An attempt is being made to create a diagnosis category for complicated grief in the DSM-V.[22][verification needed]?Critics of including the diagnosis of complicated grief in the DSM-V say that doing so will constitute characterizing a natural response as a pathology, and will result in wholesale medicating of people who are essentially normal.[22][verification needed]Shear and colleagues found an effective treatment for complicated grief, by treating the reactions in the same way as trauma reactions.[23][24]Complicated grief is not synonymous with grief. Complicated grief is characterised by an extended grieving period and other criteria, including mental and physical impairments.?[25]?An important part of understanding complicated grief is understanding how the symptoms differ from normal grief. The Mayo Clinic states that with normal grief the feelings of loss are evident. When the reaction turns into complicated grief, however, the feelings of loss become incapacitating and continue even though time passes.[26]?The signs and symptoms characteristic of complicated grief are listed as "extreme focus on the loss and reminders of the loved one, intense longing or pining for the deceased, problems accepting the death, numbness or detachment . . . bitterness about your loss, inability to enjoy life, depression or deep sadness, trouble carrying out normal routines, withdrawing from social activities, feeling that life holds no meaning or purpose, irritability or agitation, lack of trust in others."[26]?The symptoms seen in complicated grief are specific because the symptoms seem to be a combination of the symptoms found in separation as well as traumatic distress. They are also considered to be complicated because unlike normal grief these symptoms will continue regardless of the amount of time that has passed and despite treatment given from tricyclic antidepressants.[27]In the study "Bereavement and Late-Life Depression: Grief and its Complications in the Elderly" six subjects who had symptoms of complicated grief were given a dose of Paroxetine which is a selective serotonin reuptake inhibitor and showed a 50% decrease in their symptoms within a three month period. The Mental Health Clinical Research team theorizes that the symptoms of complicated grief in bereaved elderly are an alternative of post-traumatic stress. These symptoms were correlated with cancer, hypertension, anxiety, depression, suicidal ideation, increased smoking, and sleep impairments at around six months after spousal death.[27]A treatment that has been found beneficial in dealing with the symptoms associated with complicated grief is the use of serotonin specific reuptake inhibitors such as Paroxetine. These inhibitors have been found to reduce intrusive thoughts, avoidant behaviors, and hyperarousal that are associated with complicated grief. In addition psychotherapy techniques are in the process of being developed.[27][edit]Examples of bereavementThis section?needs additionalcitations?for?verification.?(April 2011)[edit]Death of a childDeath of a child can take the form of a loss in infancy such as?miscarriage?or?stillbirth[28]?or neonatal death,?SIDS, or the death of an older child. In most cases, parents find the grief almost unbearably devastating, and it tends to hold greater risk factors than any other loss. This loss also bears a lifelong process: one does not get 'over' the death but instead must assimilate and live with it.[29]Intervention and comforting support can make all the difference to the survival of a parent in this type of grief but the risk factors are great and may include family breakup or suicide.[citation needed][30]Feelings of guilt, whether legitimate or not, are pervasive, and the dependent nature of the relationship disposes parents to a variety of problems as they seek to cope with this great loss. Parents who suffer miscarriage or a regretful or coerced abortion may experience resentment towards others who experience successful pregnancies. Because of the intensity of grief emotions, irrational decisions are often made.[citation needed][edit]SuicideSuicide is a growing epidemic and over the last thirty years there has been national research trying to curb this phenomenon and gather knowledge about who is "at-risk". When a parent loses their child through suicide it is traumatic, sudden and affects all loved ones impacted by this child. Suicide leaves many unanswered questions and leaves most parents feeling hurt, angry and deeply saddened by such a loss. Parents feel they can't openly discuss their grief and feel their emotions because of how their child died and how the people around them may perceive the situation. Parents, family members and service providers have all confirmed the unique nature of suicide-related berevement following the loss of a child. They report a wall of silence that goes up around them and how people interact towards them. One of the best ways to grieve and move on from this type of loss is to find ways to keep that child as an active part of their lives. It might be privately at first but as parents move away from the silence they can move into a more proactive healing time.?[31][edit]Death of a spouseAlthough the death of a spouse may be an expected change, it is a particularly powerful loss of a loved one. A spouse often becomes part of the other in a unique way: many widows and widowers describe losing 'half' of themselves. After a long marriage, at older ages, the elderly may find it a very difficult assimilation to begin anew.At younger ages as well, a marriage relationship was often a profound one for the survivor. And finally, it must be taken into account as a factor the manner in which the spouse passed away. The survivor of a spouse who died of an illness has a different experience of such loss than a survivor of a spouse who died by, say, an act of violence. The grief, in all events, however, can always be of the most profound sort to the widow and the widower.Furthermore, most couples have a division of 'tasks' or 'labor', e.g., the husband mows the yard, the wife pays the bills, etc. which, in addition to dealing with great grief and life changes, means added responsibilities for the bereaved. Social isolation may also become imminent, as many groups composed of couples find it difficult to adjust to the new identity of the bereaved, and the bereaved themselves have great challenges in reconnecting with others. Widows of many cultures, for instance, wear black for the rest of their lives to signify the loss of their husband and their grief. Only in more recent decades has this tradition been reduced to a period of two years, while some religions such as Christian Orthodox many widows will still continue to wear black for the remainder of their lives.[citation needed][edit]Death of a parentFor a child, the death of a parent, without support to manage the effects of the grief, may result in long-term psychological harm. This is more likely if the adult carers are struggling with their own grief and are psychologically unavailable to the child. There is a critical role of the surviving parent or caregiver in helping the children adapt to a parent's death. Studies have shown that losing a parent at a young age did not just lead to negative outcomes; there are some positive effects. Some children had an increased maturity, better coping skills and improved communication. Adolescents valued other people more than those who have not experienced such a close loss.[32]When an adult child loses a parent in later adulthood, it is considered to be "timely" and to be a normative life course event. This allows the adult children to feel a permitted level of grief. Research demonstrates that the death of a parent in midlife is not a normative event by any measure, but is a major life transition. Depending on the individual, this transition can impact the child's life in many different ways. One child may evaluate his or her own life more closely, or may look into the child's own mortality. Other children may shut out friends and family while trying to process losing someone with whom they have had the longest relationship.[33]An adult may be expected to cope with the death of a parent in a less emotional way; however, the loss can still invoke extremely powerful emotions. This is especially true when the death occurs at an important or difficult period of life, such as when becoming a parent, at graduation, or at other times of emotional stress. It is important to recognize the effects that the loss of a parent can cause, and to address these effects. For an adult, the willingness to be open to grief is often diminished. A failure to accept and deal with loss will only result in further pain and suffering.[citation needed][edit]Death of a siblingThe loss of a sibling is a devastating life event. Despite this, sibling grief is often the most disenfranchised or overlooked of the four main forms of grief, especially with regard to adult siblings. However, the sibling relationship tends to be the longest significant relationship of the lifespan and siblings who have been part of each other's lives since birth, such as twins, help form and sustain each other's identities; with the death of one sibling comes the loss of that part of the survivor's identity.[citation needed]The sibling relationship is a unique one, as they share a special bond and a common history from birth, have a certain role and place in the family, often complement each other, and share genetic traits. Siblings who enjoy a close relationship participate in each other's daily lives and special events, confide in each other, share joys, spend leisure time together (whether they are children or adults), and have a relationship that not only exists in the present but often looks toward a future together (even into retirement).[citation needed]Siblings who play a major part in each other's lives are essential to each other. Adult siblings eventually expect the loss of aging parents, the only other people who have been an integral part of their lives since birth, but they do not expect to lose their siblings early; as a result, when a sibling dies, the surviving sibling may experience a longer period of shock and disbelief.[citation needed]Overall, with the loss of a sibling, a substantial part of the surviving sibling's past, present, and future is also lost. If siblings were not on good terms or close with each other, then intense feelings of guilt may ensue on the part of the surviving sibling (guilt may also ensue for having survived, not being able to prevent the death, having argued with their sibling, etc.)[34][edit]Loss during childhoodWhen a parent or caregiver dies or leaves, children may have symptoms of psychopathology, but they are less severe than in children with major depression.[35]?The loss of a parent, grandparent or sibling can be very troubling in childhood, but even in childhood there are age differences in relation to the loss. A very young child, under one or two, may be found to have no reaction if a carer dies, but other children may be affected by the loss.At a time when trust and dependency are formed, a break even of no more than separation can cause problems in well-being; this is especially true if the loss is around critical periods such as 8?12 months, when attachment and separation are at their height information, and even a brief separation from a parent or other person who cares for the child can cause distress.[36]Even as a child grows older, death is still difficult to fathom and this affects how a child responds. For example, younger children see death more as a separation, and may believe death is curable or temporary: in one case, a child believed her deceased mother could be restored with?band-aids.[citation needed]?Reactions can manifest themselves in "acting out" behaviors: a return to earlier behaviors such as sucking thumbs, clinging to a toy or angry behavior; though they do not have the maturity to mourn as an adult, they feel the same intensity.[citation needed]?As children enter pre-teen and teen years, there is a more mature understanding.Adolescents may respond by?delinquency, or oppositely become "over-achievers": repetitive actions are not uncommon such as washing a car repeatedly or taking up repetitive tasks such as sewing, computer games, etc. It is an effort to stay above the grief.[citation needed]?Childhood loss as mentioned before can predispose a child not only to physical illness but to emotional problems and an increased risk for suicide, especially in the adolescent period.[citation needed]Children can experience grief as a result of losses due to causes other than death. For example, children who have been physically, psychologically and/or sexually abused often grieve over the damage to, or loss of, their ability to trust. Since such children usually have no support or acknowledgement from any source outside the family unit, this is likely to be experienced as?disenfranchised grief.[citation needed]Relocations?can cause children significant grief, particularly if they are combined with other difficult circumstances, such as neglectful and/or abusive parental behaviors, other significant losses, etc.[37][38]Loss of a friend or classmateChildren may experience a loss during their childhood through the death of a friend or a classmate. This can be especially traumatic if the classmate dies during school. This can happen through sports, illness, bullying and tragically school shootings. Of course a friend or classmate could die off school grounds and it is extremely important to help students cope with their intense feelings and assure them they are not alone. The schools regardless of where one of the students dies should establish a children's support group to relieve the affects of such a quick loss or traumatic loss and alleviate any other events that may come from this loss. This type of service has positively impacted students and decreased levels of PTSD and trauma related anxiety. Caregivers, teachers and professionals can encourage the children to express their feelings through music, art and writing to reduce the re-traumatizing affect of repeatedly bring up the catastrophic event.?[39][edit]Other lossesPeople who become unemployed, such as these California workers, may face grief from the loss of their jobParents may grieve due to loss of children through means other than death, for example through loss of?custody?in divorce proceedings; legal termination ofparental rights?by the government, such as in cases of?child abuse; through kidnapping; because the child voluntarily left home (either as a runaway or, for children over 18, by leaving home legally); or because an adult refuses or is unable to have contact with a parent. This loss differs from the death of a child in that the grief process is prolonged or denied because of hope that the relationship will be restored.[citation needed]Grief may occur after the loss of a romantic relationship (i.e. divorce or break up), a vocation, a pet (animal loss), a home, children leaving home (empty nest syndrome), sibling(s) leaving home, a friend, a favored appointment or desire, a faith in one's religion, etc. A person who strongly identifies with their occupation may feel a sense of grief if they have to stop their job due to retirement, being laid off, injury, or loss of certification. Those who have experienced a loss of trust will often also experience some form of grief.[citation needed][edit]Professional supportMany people grieve without professional help[citation needed]. Some, however, may seek additional support from licensedpsychologists?or?psychiatrists. And support resources available to the bereaved may include?grief counseling, professional support-groups or educational classes, and peer-led support groups. In the United States of America, local?hospice?agencies may provide a first contact for those seeking bereavement support.[citation needed]It is important to recognize when grief has turned into something more serious, thus mandating contacting a medical professional. According to?MedlinePlus, grief can result in depression or alcohol- and drug-abuse and, if left untreated, it can become severe enough to impact daily living.[40]?It recommends contacting a medical professional if "you can?t deal with grief, you are using excessive amounts of drugs or alcohol, you become very depressed, or you have prolonged depression that interferes with your daily life."[40]?Other reasons to seek medical attention may include: "Can focus on little else but your loved one?s death, have persistent pining or longing for the deceased person, have thoughts of guilt or self-blame, believe that you did something wrong or could have prevented the death, feel as if life isn?t worth living, have lost your sense of purpose in life, wish you had died along with your loved one."[26]Professionals can use multiple ways to help someone cope and move through their grief. Lichtenthal and Cruess (2010) studied how bereavement-specific written disclosure had benefits in helping adjust to loss, and in helping improve the effects of post-traumatic stress disorder (PTSD), prolonged grief disorder, and depression. Directed writing helped many of the individuals who had experienced a loss of a significant relationship. It involved individuals trying to make meaning out of the loss through?sense making, (making sense of what happened and the cause of the death), or through?benefit finding?(consideration of the global significance of the loss of one's goals, and helping the family develop a greater appreciation of life). This?meaning-making?can come naturally for some, but many need direct intervention to "move on".[41][edit]Cultural diversity in grievingMain article:?MourningEach society specifies manners such as rituals, styles of dress, or other habits, as well as attitudes, in which the bereaved are encouraged or expected to take part. An analysis of non-Western cultures suggests that beliefs about continuing ties with the deceased varies. In Japan, maintenance of ties with the deceased is accepted and carried out through religious rituals. In the Hopi of Arizona, the deceased are quickly forgotten and life continues on.[citation needed]Different cultures grieve in different ways, but all have ways that are vital in healthy coping with the death of a loved one.[42]?The American family's approach to grieving was depicted in "The Grief Committee", by?T. Glen Coughlin. The short story gives an inside look at how the American culture has learned to cope with the tribulations and difficulties of grief. (The story is taught in the course, The Politics of Mourning: Grief Management in a Cross-Cultural Fiction. Columbia University)
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